Root Cause Analysis (RCA) Frameworks & Tools

1. ROOT CAUSE ANALYSIS: FRAMEWORKS & TOOLS Uncover the Why: Master Root Cause Analysis for Lasting Solutions C:\Users\Allan BigMac\Documents\000 OEC\Logo\The Logo Company\FINAL\OperationalExD24aR02bP01ZL\TRANSPARENT.png © Operational Excellence Consulting. All rights reserved.

2. NOTE: This is a PARTIAL PREVIEW. To download the complete presentation, please visit: https://www.oeconsulting.com.sg NOTE: This is a PARTIAL PREVIEW. To download the complete presentation, please visit: https://www.oeconsulting.com.sg LEARNING OBJECTIVES Demonstrate the use of best practices to avoid common pitfalls and ensure robust analysis and actionable outcomes. Describe the purpose, applications, and advantages of various RCA tools such as the Fishbone Diagram, 5 Whys, and FMEA. Analyze problems systematically using step-by-step procedures for each framework, identifying root causes effectively. Compare and contrast frameworks based on their advantages, limitations, and suitability for specific industries or challenges. 2 © Operational Excellence Consulting

3. CONTENTS 1 6 Fishbone Diagram Current Reality Tree (CRT) 2 7 5 Whys Analysis Kepner-Tregoe Problem Analysis 3 8 Fault Tree Analysis (FTA) Pareto Analysis (80/20 Rule) 4 9 Failure Mode and Effects Analysis (FMEA) Bowtie Diagram 5 10 Root Cause Analysis Tree Diagram Scatter Diagram 3 © Operational Excellence Consulting

4. “ symptoms rather than eliminate underlying causes. When we fail to grasp the systemic source of problems, we are left to ‘push on’ PETER SENGE The Fifth Discipline 4 © Operational Excellence Consulting

5. FISHBONE DIAGRAM (ISHIKAWA DIAGRAM) Description Purposes When to Use It ▪ A visual brainstorming tool that organizes potential causes of a problem into categories to identify and analyze root causes systematically. ▪ Identify potential root causes in a structured way. ▪ Organize causes into logical categories for analysis. ▪ Facilitate collaborative problem-solving. ▪ When causes of a problem are unclear or multifaceted. ▪ To brainstorm potential factors leading to recurring issues. ▪ During quality improvement initiatives. 5 © Operational Excellence Consulting

6. FISHBONE DIAGRAM (MANUFACTURING) CAUSES EFFECT Machines Manpower Methods Cause Problem Statement Environment Measurements Materials 6 © Operational Excellence Consulting

7. 5 WHYS ANALYSIS A problem-solving technique to identify the root cause of an issue. Problem ● Why? Digging deeper Why? Involves asking “why” multiple times (typically five) to drill down to the underlying cause. ● Why? Why? Why? Root cause 7 © Operational Excellence Consulting

8. EXAMPLE 2: 5 WHYS ANALYSIS ILLUSTRATIVE Why? Because… Oil leaks from the cylinder rod when activated. 1 Why is there oil on the floor? 2 Why did oil leak? The O-ring was cut. 3 Why was the O-ring cut? The rod was flawed. 4 Why was the rod flawed? Dirt in the oil abrades the rod. There are holes and gaps on the upper plate of the tank. 5 Why did dirt get in the oil? 8 © Operational Excellence Consulting

9. FAULT TREE ANALYSIS (FTA) Description Purposes When to Use It ▪ A logic-based diagram that models all potential causes of a specific system failure using logical gates (AND, OR) to show cause-effect relationships. ▪ Identify and analyze potential failure points in systems. ▪ Assess risks quantitatively by calculating failure probabilities. ▪ Aid in designing more reliable systems or processes. ▪ During the design phase of critical systems. ▪ To investigate failures in safety-critical industries like nuclear energy, aviation or healthcare. ▪ For comprehensive risk assessments. 9 © Operational Excellence Consulting

10. EXAMPLE 1: FAULT TREE ANALYSIS (FTA) –CAR HITTING AN OBJECT ILLUSTRATIVE This FTA example explores the reasons a car hits an object. ● Car hits object The analysis pinpoints two key events: driver does not see the object (due to factors like an obstructed view, intoxication, or sleep) and car fails to brake (caused by excessive speed or weak brakes). ● AND Driver does not see object Car fails to brake OR OR Logical gates (AND/OR) show how these events interact to lead to the top-level accident. ● Object just around corner Driver drunk Driver asleep Car going too fast Brakes weak © Operational Excellence Consulting 10

11. EXPLORING DFMEA AND PFMEA: DESIGN vs. PROCESS FOCUSED RISK ANALYSIS Design FMEA (DFMEA) Process FMES (PFMEA) ▪ Explores failures from material properties, geometry, tolerances, system interactions, and environmental impacts. ▪ Identifies process-related failures from human errors, processing methods, material issues, machinery, or environment. ▪ Focuses on design decisions impacting performance, safety, and product lifecycle. ▪ Aims to improve process reliability, product quality, and minimize safety risks. 11 © Operational Excellence Consulting

12. EXAMPLE OF AN FMEA FORM ILLUSTRATIVE FMEA Form Process Name: Process Owner: Prepared by: FMEA Date (Orig.) Page: Rev. of DECTECTION (D) OCCURRENCE OCCURRENCE DECTECTION SEVERITY (S) Responsibility & Target Completion Date SEVERITY Process Step/ Input Potential Failure Mode Potential Failure Effects Potential Causes Current Controls Actions Recommended RPN RPN (O) Actions Taken How often does the cause of What are the actions for eliminating or reducing the occurrence of the cause, or improving detection of the cause or failure mode? How severe is the effect on How well can you detect the failure mode occur? cause or failure mode? What controls and procedures exist that either prevent or detect the cause of the failure mode? What are the completed actions taken with the recalculated RPN? the customer? What causes the process step or key input to go wrong? Who is S x O x D What is the process step or key input under investigation? What can go wrong with the process step or key input? What is the impact on the customer or key output variables? responsible for the action? When should it be completed? 0 0 0 0 0 0 0 0 0 0 Post-improvement activities Improvement activities Initial development of the FMEA 12 © Operational Excellence Consulting

13. UNDERSTANDING THE ROOT CAUSE TREE MODEL The Root Cause Tree Model is a structured visual tool used to systematically trace a problem back to its underlying causes, root causes, and corrective actions or solutions. ● Root Cause Solution Cause Root Cause Solution Problem Cause Root Cause Solution It organizes these elements in a clear, hierarchical format, showing their logical relationships. ● Root Cause Solution Cause Root Cause Solution © Operational Excellence Consulting 13

14. STEPS TO CONSTRUCT A ROOT CAUSE TREE DIAGRAM Define the Problem: Clearly articulate the issue at the top of the tree diagram. Ensure everyone agrees on the problem statement. 1. Identify Major Causes: Brainstorm broad categories or initial causes contributing to the problem. Represent these as branches. 2. Drill Down Further: For each major cause, continue breaking it down into sub-causes by asking "Why?" until the root causes are identified. 3. Validate Root Causes: Review the tree to ensure all root causes are logical and supported by evidence. Adjust or expand branches if necessary. 4. Continued on the next slide… 14 © Operational Excellence Consulting

15. EXAMPLE: CURRENT REALITY TREE (CRT) DIAGRAM ILLUSTRATIVE (UDE1) (UDE2) (UDE3) Radio sounds distorted Car’s engine will not start Air conditioning is not working Engine needs fuel in or to run Fuel is not getting to the engine Air is not able to circulate The speakers are obstructed There is water in the fuel line The air intake is full of water The speakers are under water The car is in the swimming pool The handbrake stops the car from rolling into the swimming pool The handbrake is faulty 15 © Operational Excellence Consulting

16. CURRENT REALITY TREE DIAGRAM: ADVANTAGES AND LIMITATIONS Advantages Limitations ▪ Helps identify systemic causes, not just symptoms. ▪ Time-consuming for large systems. ▪ Effective for addressing complex, multi-layered problems. ▪ Requires skilled facilitation. ▪ Can overwhelm users with complexity. ▪ Provides a clear, visual analysis. 16 © Operational Excellence Consulting

17. PARETO ANALYSIS (80/20 RULE) Examples: 80% of your work results from 20% of your effort ● Effort Result 80% of your net income comes from 20% of your customers ● 20% 80% 80% of problems can be traced back to 20% of root causes 80% ● 20% 80% of corrective and preventive actions (CAPA) result from 20% of identified causes ● Important Not Important 17 © Operational Excellence Consulting

18. EXAMPLE 1: PARETO ANALYSIS –PIZZA DEFECTS ILLUSTRATIVE Pareto Chart of Pizza Defects 35 120% 30 100% 25 Cumulative Percent 80% Occurrences 20 60% 15 40% 10 20% 5 - 0% Forgot Breadstic ks 7 90% 6% Driver Had No Change 4 93% 3% Wrong Toppings Pizza Cold Pizza Late Wrong Crust Tastes Bad Wrong Price Driver Rude Smashed in Box 3 96% 3% All other Quantity Cum % % of Total 29 25% 25% 25 46% 21% 22 64% 19% 13 75% 11% 10 84% 8% 2 1 2 97% 2% 98% 1% 100% 2% 18 © Operational Excellence Consulting

19. BOWTIE DIAGRAM Description Purposes When to Use It ▪ A visual tool that links potential causes of a risk to its consequences, with preventive and mitigating controls forming a “bowtie” structure. ▪ Visualize the cause- and-effect pathways of a risk. ▪ Identify gaps in preventive and mitigating controls. ▪ Enhance risk management and decision-making. ▪ For managing safety- critical risks. ▪ During risk assessments in industries like aviation, oil and gas, or healthcare. ▪ To communicate complex risk scenarios clearly to stakeholders. 19 © Operational Excellence Consulting

20. EXAMPLE: BOWTIE DIAGRAM FOR A DATA BREACH INCIDENT ILLUSTRATIVE Threats or Causes Top Event Consequences Preventive Barriers Mitigating Barriers Poor password management Loss of customer trust Strong password policies Data encryption Data Breach Insufficient employee training Regular security training Incident response plan Financial loss Legal Legal compliance monitoring Vulnerable software Software updates repercussions 20 © Operational Excellence Consulting

21. “ results. Insanity is doing the same thing, over and over again, but expecting different ALBERT EINSTEIN 21 © Operational Excellence Consulting

22. ABOUT OPERATIONAL EXCELLENCE CONSULTING Operational Excellence Consulting is a distinguished management consultancy based in Singapore. Our firm specializes in driving transformative growth and innovation by maximizing customer value and minimizing waste through the strategic adoption of Design Thinking and Lean management practices. For further details, please visit www.oeconsulting.com.sg Logo Fb / Logo Fb Png / How the hyperconnected are X Logo (Twitter | 01) - PNG Logo Women In Wilmington for Networking © Operational Excellence Consulting